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DURHAM, N.C. -- Not only does stress management appear to
reduce the long-term chances of heart patients having another
cardiac event, but a new analysis by Duke University Medical
Center researchers and the American Psychological Association
demonstrates that this approach also provides an immediate and
significant cost savings.

In terms of both financial costs and reducing cardiac
events, moreover, the benefits of stress management seem to
exceed those of both exercise and usual heart care.

The team found a financial benefit of stress management
strategies within the first year of the study. Average costs
for patients who utilized stress management were $1,228 per
patient during the first year, as compared to $2,352 per
patient for those who exercised and $4,523 per patient for
those who received usual care.

Moreover, the researchers found, the financial benefit of
stress management was maintained over time. Average costs rose
only to $9,251 per patient during the fifth year for those who
used stress management strategies, compared to $15,688 per
patient for those who exercised and $14,997 per patient for
those who received usual care. Average costs per patient per
year during the five years were $5,998 for those who used
stress management, $8,689 for those who exercised and $10,338
for those who received usual care.

The medical outcomes also were notable. Patients in both the
"exercise group" and the "usual care group" averaged 1.3
cardiac events ? bypass surgery, angioplasty, heart attack or
death ? by the fifth year of follow-up. Those in the "stress
management group," by contrast, averaged only 0.8 such events
during the same period.

"These results extend our earlier work that showed stress
management programs reduce cardiac events in the short term,
and now we can demonstrate a long-term benefit," said Duke
psychologist James Blumenthal, who led the study. "While
confirming the long-term medical benefit of a stress management
program for heart patients, the results of this analysis
demonstrate a significant financial benefit as well."

The results were published in the Jan. 15, 2002 issue of the
American Journal of Cardiology. The study was supported by
three grants from the National Institutes of Health.

In the study, 94 male patients with established coronary
artery disease were assigned to one of three groups. The first
group received 1.5 hours per week of stress management training
for 16 weeks, the second group exercised three times per week
during a four-month period and the third received usual and
traditional care. The researchers then conducted follow-up on
the patients annually for five years.

"While we were not surprised by the overall beneficial
effects of stress management, we were surprised and pleased
that the effects accrued so rapidly," said Russ Newman,
executive director for professional development at the American
Psychological Association (www.apa.org).

"The economic portion of this analysis is very important,"
Newman continued. "While the medical literature supports the
long-term economic benefits of psychological interventions,
this study shows an immediate and sustainable cost saving.
These findings help us immeasurably in making the case to
health care systems and employers that psychological approaches
can help their members at risk for cardiovascular disease."

Stress management programs begin by helping patients
identify the physical, behavioral, emotional and cognitive
symptoms of stress. Patients then are taught how to react
realistically and positively to these stresses.

"One of the benefits of a stress management program is that
once you've learned how to recognize and handle the stresses of
everyday life, it tends to stay with you," Blumenthal said.
"This is unlike exercise, which must be maintained for the
benefits to be realized."

While he does not know why the benefits of exercise seemed
to diminish over time, Blumenthal speculates that the "exercise
group" may not have kept up with their exercise with the same
frequency or intensity as the original four-month period.

Psychologist Geoffrey Reed, co-author on the paper and
assistant executive director for professional development at
the APA, whose work on behalf of the APA includes demonstrating
to health care delivery systems the value of psychological
approaches to treating disease, believes the results of this
study gives him added ammunition.

"In general, psychosocial approaches are not taken into
account enough by the medical community," Reed said.
"Cardiologists have been fairly accepting as a group because
the link between behavior and cardiovascular events is more
obvious, but outside of cardiology, the medical establishment
continues to underestimate the importance of psychological
factors in the disease process."

For their economic analysis, the team used data supplied by
the U.S. Public Health Service Panel on Cost-Effectiveness in
Health and Medicine, which uses national averages in
determining the costs of different procedures and events.

Other Duke members of the teams included Michael Babyak, Dr.
Wei Jiang, Dr. Christopher O'Connor, Dr. Robert Waugh, Eric
Eisenstein, Dr. Daniel Mark and Andrew Sherwood. Other members
of the team were Pamela Woodley and Richard Irwin, both from
the accounting firm of Pricewaterhouse Coopers, who conducted
the financial analysis.

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